MEDICARE: MOORE DENTAL CARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry
2	332BC3200X	Customized Equipment (DME)	3043	AR

General Provider Information

NPI Number	:	1194154443
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOORE DENTAL CARE

Provider Business Mailing Address
First Line	:	2913 SOUTH 74TH STREET
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903
Country	:	US
Telephone Number	:	479-484-5050
Fax Number	:	479-484-5052

Provider Business Practice Location Address
First Line	:	2913 SOUTH 74TH STREET
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903
Country	:	US
Telephone Number	:	479-484-5050
Fax Number	:	479-484-5052

Authorized Official
Title or Position	:	OWNER
Name	:	DR. WILLIAM WESLEY MOORE
Credential	:	DDS
Telephone Number	:	479-484-5050

Provider Enumeration Date	:	11/07/2013
Last Update Date	:	11/09/2020

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